CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED

Claims Processing Centre: Hari Nivas Towers, Second Floor,

Toll Free Ph no: 1800 200 5544 Toll Free Fax no: 1800 425 2200
e-mail:Customercare@cholams.murugappa.com;
www.cholainsurance.com

Membership Number:

Suite

Deluxe Room

Others

k) Type of hospitalization: Emergency / Planned

Filled claim form duly signed

Copy of the claim intimation
Final Hospital Bill with detailed break-up

vi. External aids:

Rs.

Hospital bill payment receipt

Rs.

Detailed hospital discharge summary

vii. OPD dental:

Rs.

viii.OPD:

ix.Eye check up cost:

Rs.

x. Minor accompaniment daily cash: Rs.

xi.

Rs.

Pharmacy / medical bills which supporting doctor

prescription
Investigation / lab reports supporting the diagnosis.
Operation theatre notes for surgical cases
Invoice / sticker for the implants used in the treatment.
External Aids vendors supported by the proper
prescription from Doctor.
Home Hospitalization treatment - Certicate from
treating doctor specifying reasons for Home
Hospitalization
Obstetric History for maternity claims (GPAL Status)
Copy of MLC / FIR / in case of road trafc accidents
(RTA)
AML documents (Proof of Identity with photo, Address
proof) for above 1 lac claims

Note : Please enclose a cancelled cheque / copy of the same, NEFT cannot be facilitated without the cancelled cheque / copy

DECLARATION BY THE INSURED:

Date: D

Place:

SECTION H

I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement,
suppression or concealment of any material fact, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA / insurance com pany, to seek necessary
medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have
included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any.

Signature of the Insured

GUIDANCE FOR FILLING CLAIM FORM PART A (To be lled in by the insured)
DATA ELEMENT

DESCRIPTION

FORMAT

SECTION A - DETAILS OF PRIMARY INSURED

a)

Policy No.

Enter the policy number

Enter the social insurance number or the certicate number of
social health insurance scheme

As allotted by the insurance company

b)

SI. No/ Certicate No.

c)

Company TPA ID No.

Enter the TPA ID No

d)

Name

Enter the full name of the policyholder

License number as allotted by IRDA and

printed in TPA documents.
Surname, First name, Middle name

e)

Address

Enter the full postal address

Include Street, City and Pin Code

As allotted by the organization

Tick Yes or No

b)

SECTION B - DETAILS OF INSURANCE HISTORY

Currently covered by any other Mediclaim / Health
Indicate whether currently covered by another Mediclaim /
Insurance?
Health Insurance
Date of Commencement of rst Insurance without break
Enter the date of commencement of rst insurance

c)

Company Name

Enter the full name of the insurance company

Name of the organization in full

Policy No.

Enter the policy number

As allotted by the insurance company

Sum Insured

Enter the total sum insured as per the policy

In rupees

Have you been Hospitalized in the last 4 years

Indicate whether hospitalized in the last 4 years

Tick Yes or No

Date

Enter the date of hospitalization

Use mm-yy format

Diagnosis
Previously Covered by any other Mediclaim/ Health
Insurance?
Company Name

Enter the diagnosis details

Indicate whether previously covered by another Mediclaim /
Health Insurance
Enter the full name of the insurance company

Open Text

a)

d)

e)
f)

Use dd-mm-yy format

Tick Yes or No
Name of the organization in full

SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED

a)

Name

Enter the full name of the patient

Surname, First name, Middle name

b)

Gender

Indicate Gender of the patient

Tick Male or Female

c)

Age

Enter age of the patient

Number of years and months

d)

Date of Birth

Enter Date of Birth of patient

Use dd-mm-yy format

e)

Relationship to primary Insured

Indicate relationship of patient with policyholder

Tick the right option. If others, please specify.

f)

Occupation

Indicate occupation of patient

Tick the right option. If others, please specify.

g)

Address

Enter the full postal address

Include Street, City and Pin Code

h)

Phone No

Enter the phone number of patient

Include STD code with telephone number

i)

E-mail ID

Enter e-mail address of patient

Complete e-mail address

SECTION D - DETAILS OF HOSPITALIZATION

a)

Name of Hospital where admitted

Enter the name of hospital

Name of hospital in full

b)

Room category occupied

Indicate the room category occupied

Tick the right option

c)
d)

Indicate reason of hospitalization

Tick the right option

Enter the relevant date

Use dd-mm-yy format

e)

Hospitalization due to
Date of Injury/Date Disease rst detected/ Date of
Delivery
Date of admission

Enter date of admission

Use dd-mm-yy format

f)

Time

Enter time of admission

Use hh:mm format

g)

Date of discharge

Enter date of discharge

Use dd-mm-yy format

h)

Time

Enter time of discharge

Use hh:mm format

i)

If Injury give cause

Indicate cause of injury

Tick the right option

If Medico legal

Indicate whether injury is medico legal

Tick Yes or No

Reported to Police

Indicate whether police report was led

Tick Yes or No

MLC Report & Police FIR attached

Indicate whether MLC report and Police FIR attached

Tick Yes or No

j)

System of Medicine

Enter the system of medicine followed in treating the patient

Open Text

a)

Details of Treatment Expenses

Enter the amount claimed as treatment expenses

In rupees (Do not enter paise values)

b)

Claim for Domiciliary Hospitalization

Indicate whether claim is for domiciliary hospitalization

Tick Yes or No

c)

Details of Lump sum/ cash benet claimed

Enter the amount claimed as lump sum/ cash benet

In rupees (Do not enter paise values)

d)

Claim Documents Submitted-Check List

Indicate which supporting documents are submitted

Tick the right option

SECTION E - DETAILS OF CLAIM

SECTION F - DETAILS OF BILLS ENCLOSED

Indicate which bills are enclosed with the amounts in rupees
SECTION G - DETAILS OF PRIMARY INSUREDS BANK ACCOUNT
a)

PAN

Enter the permanent account number

b)

Account Number

Enter the bank account number

As allotted by the bank

c)

Bank Name and Branch

Name of the Bank in full

d)

Cheque/ DD payable details

e)

IFSC Code

Enter the bank name along with the branch

Enter the name of the beneciary the cheque/ DD should be
made out to
Enter the IFSC code of the bank branch
SECTION H - DECLARATION BY THE INSURED

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.

As allotted by the Income Tax department

Name of the individual/ organization in full

IFSC code of the bank branch in full

ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

GUIDANCE FOR FILLING CLAIM FORM PART B (To be lled in by the hospital)
DATA ELEMENT

DESCRIPTION

FORMAT

SECTION A - DETAILS OF HOSPITAL

a)

Name of Hospital

Enter the name of hospital

Name of hospital in full

b)

Hospital ID

Enter ID number of hospital

As allocated by the TPA

c)

Type of Hospital

Indicate whether In network or non network nospital

Tick the right option

d)

Name of treating doctor

Enter the name of the treating doctor

Name of doctor in full

e)

Qualification

Abbreviations of educational qualications

f)

Registration No. with State Code

g)

Phone No.

Enter the qualifications of the treating doctor

Enter the registration number of the doctor along with the state
code
Enter the phone number of doctor

As allocated by the Medical Council of India

Include STD code with telephone number

SECTION B DETAILS OF THE PATIENT ADMITTED

a)

Name of Patient

Enter the name of hospital

Name of hospital in full

b)

IP Registration Number

Enter insurance provider registration number

As allotted by the insurance provider

c)

Gender

Indicate Gender of the patient

Tick Male or Female

d)

Age

Enter age of the patient

Number of years and months

e)

Date of Admission

Enter date of admission

Use dd-mm-yy format

f)

Time

Enter time of admission

Use hh:mm format

g)

Date of Discharge

Enter date of discharge

Use dd-mm-yy format

h)

Time

Enter time of discharge

Use hh:mm format

i)

Type of Admission

Indicate type of admission of patient

Tick the right option

j)

If Maternity
Date of Delivery

Enter Date of Delivery if maternity

Use dd-mm-yy format

Gravida Status

Enter Gravida status if maternity

Use standard format

k)

Status at time of discharge

Indicate status of patient at time of discharge

Tick the right option

a)

ICD 10 Code

SECTION C DETAILS OF AILMENT DIAGNOSED (PRIMARY)

Enter the ICD 10 Code and description of the primary
diagnosis
Enter the ICD 10 Code and description of the additional
diagnosis
Enter the ICD 10 Code and description of the co-morbidities

Standard Format and Open text

Procedure 1

Enter the ICD 10 PCS and description of the first procedure

Standard Format and Open text

Procedure 2

Enter the ICD 10 PCS and description of the second procedure

Standard Format and Open text

Procedure 3

Enter the ICD 10 PCS and description of the third procedure

Standard Format and Open text

Details of Procedure

Enter the details of the procedure

Indicate whether present ailment is a complication of some preexisting disease
Indicate whether pre-authorization obtained

Open text

Tick Yes or No
As allotted by TPA

Primary Diagnosis
Additional Diagnosis
Co-morbidities
b)

Standard Format and Open text

Standard Format and Open text

ICD 10 PCS

c)

Present Ailment is a Complication of PED

d)

Pre-authorization obtained

e)
f)

Pre-authorization Number
If authorization by network hospital not obtained, give
reason
Hospitalization due to injury

Enter pre-authorization number

Enter reason for not obtaining pre-authorization number

Open text

Indicate if hospitalization is due to injury

Tick Yes or No

Cause
If injury due to substance abuse/alcohol consumption,
test conducted to establish this
Medico Legal

Indicate cause of injury

Tick the right option

Indicate whether test conducted

Tick Yes or No

Indicate whether injury is medico legal

Tick Yes or No

Reported To Police

Indicate whether police report was led

Tick Yes or No

FIR No.

Enter rst information report number

As issued by police authorities

If not reported to police, give reason

Enter reason for not reporting to police

Open Text

g)

Tick Yes or No

SECTION D CLAIM DOCUMENTS SUBMITTED-CHECK LIST

Indicate which supporting documents are submitted
SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL
a)

Address

Enter the full postal address

Include Street, City and Pin Code

b)

Phone No.

Enter the phone number of hospital

Include STD code with telephone number

c)

Registration No.

Enter the registration number of patient

As allocated by the Hospital

d)

PAN

Enter the permanent account number

As allotted by the Income Tax department

e)

Number of Inpatient Beds

Enter the number of inpatient beds

Digits

f)

Facilities available in the hospital

Indicate facilities available in the hospital

Tick the right option. If others, please specify

SECTION F - DECLARATION BY THE INSURED

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
SECTION G - DECLARATION BY THE HOSPITAL
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp